Provider Demographics
NPI:1427357904
Name:SATHISSARAT, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SATHISSARAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13555 GOLDEN MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-9671
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:88 MDG/SGHJ
Practice Address - Street 2:4881 SUGAR MAPLE DR. BLDG 830
Practice Address - City:WRIGHT-PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-257-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-23
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.0286411223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program